Wallace

T. Miller,

Jr, MD

Cryptococcal with AIDS:

#{149} Jonathan

1990;

O

#{149} Wallace

pulmonary

infec-

tions and

are a major source of mombidity mortality in patients with acquired immunodeficiency syndrome (AIDS). In several series of patients with AIDS who had pneumonia, cryptococcal pneumonia represented 2%-15% of all cases (1-4). Little has been written about the manifestations and radiographic appearance of cnyptococcal pulmonary infections in patients with AIDS. We report here our findings from seven cases.

METHODS We retrospectively biologic

and

reviewed

cytologic

the

records

micro-

at three

in-

stitutions (the Graduate Hospital of Philadelphia, the Hospital of the University of Pennsylvania, and the Veterans Administration

Center

to find

patients in whom had been identified

cultures choalveolar

viewed

or cytologic lavage

Cryptococcus from then

medical to identify who had

Patients

were

neolung of bronre-

records

and

those paa pulmonary

considered

to

cryptococcal pulmonary infection had both pulmonary symptoms

(cough, diographic

dyspnea) findings

be isolated

from the lung ing cytologic pies and cultured (cerebrospinal tients another

of Philadelphia)

examination fluid. We

radiographs with AIDS

infection.

could

Hospital

the patients’

chest tients

have they

175:725-728

T. Miller,

Infection Appearance’

PPORTUNISTIC

formans

meningitis.

Index terms: Acquired immunodeficiency syndrome (AIDS), 60.2518 #{149} Cryptococcosis, 60.2054 #{149} Lung, infection, 60.2054 #{149} Meningitis, 10.2054 Radiology

MD

Pulmonary Radiographic

The clinical, laboratory, and radiographic findings in seven patients with acquired immunodeficiency syndrome (AIDS) and cryptococcal pulmonary infections were reviewed. The infection was most commonly seen on radiographs as lymphadenopathy, interstitial infiltrates, or both. Interstitial infiltrates were commonly nodular. Large nodules or alveolar infiltrates, the most common findings at presentation in both immunocompetent patients and immunocompromised patients without AIDS, were not present in our series. Isolated pleural effusion was seen as the only radiographic finding in one case. Meningitis was present in six of seven cases and was neurologically silent in five of six cases. Cryptococcal pneumonia in AIDS patients should prompt a search for neurologically silent cryptococcal

M. Edelman,

and

abnormal chest and if C neoformans

by means

or could evaluation fluid

were excluded pathogen

be

ra-

of culture identified of the lung

from other body [CSF], blood). was

if

from our isolated

review from

dunsamfluids Paif the

RESULTS

From

the

Departments

of Radiology

(W.T.M., Jr, W.T.M.) and Medicine (J.M.E.), Hospital of the University of Pennsylvania, 3400 Spruce St. Philadelphia, PA 19104. Received October 24, 1989; revision requested November 20; revision received January 18, 1990; accepted January 23. Address reprint requests to W.T.M. © RSNA, 1990

in Patients

ding yeast, characteristic of C neoformans, was detected at cytologic evaluation of the BAL fluid from three others. These patients also had CSF cultures that were positive for C neo-

f onmans.

Among the two patients who did not undergo bronchoscopy, C neofonmans was cultured from the pleural fluid, blood, and CSF of one. In the other, a sputum Gram stain revealed yeast, and C neoformans was cultured from the blood and CSF. In addition, this patient had a diffuse rash, shown by means of histologic evaluation to be secondary to cryptococcal infection of the skin. The clinical data, means of diagnosis, and chest radiographic patterns of the seven patients are summarized in the Table. Presenting symptoms were nonspecific; all patients had feyen, three had dyspnea, three had cough, and two had diarrhea. One patient had lost weight, another had a skin rash, and a third patient was confused and ataxic. Arterial blood gas results were available for six of seven patients. Most patients had an elevated alveolar-arterial gradient, which indicated pulmonary parenchymal disease. Interstitial infiltrates with adenopathy were present in two patients (Fig 1); interstitial infiltrates alone were present in two patients (Figs 2, 3); and findings of hilam and/or mediastinal lymphadenopathy without infiltrates were present in two patients.

that

lung.

1

MD

Seven men with AIDS (aged 20-58 years) met the criteria for cryptococcal pulmonary infection. In five patients, specimens of bronchoalveolar lavage (BAL) fluid obtained at bronchoscopy yielded results positive for cryptococcal organisms. C neofonmans was cultured from the BAL fluid obtamed from two patients, and bud-

Of the demonstrated

four

chest radiognaphs interstitial infil-

trates, two showed pattern, somewhat any tuberculosis,

a diffuse nodular resembling milialthough the nod-

ules

and

fined showed

were

(Fig

larger

slightly

less

2). One chest radiograph focal nodular interstitial

de-

in-

Abbreviations: AIDS = acquired immunodeficiency syndrome, BAL = bronchoalveolar Iavage, CSF = cerebrospinal fluid, CNS central nervous system, TB tuberculosis.

725

Clinical,

Laboratory,

and Radiographic

Findings

in Seven

Patients

with

AIDS

and Cryptococcal

Pulmonary

Infections

Arterial

Blood Cases Patient

Duration

No/Age

Risk

(y)

Recovery

Factors

Status

Symptoms

H

R

Dyspnea, cough

2/25

H, IVDA

D

3/28

NA

R

4/29

H

D

Fever, chills, cough, diarrhea Dyspnea, fever, arrhea Fever, dyspnea, cough, rash

5/58

H

D

6/35

IVDA

R

7/46

H

R

Note.-BAL intravenous

=

drug

bronchoalveolar abuse, NA

with

amphotenicin

B.

DISCUSSION C neoformans is a nonmycelial budding yeast found in soil contaminated by pigeon or chicken excreta. Although it rarely causes pulmonary infections in humans, of those infected, 50%-80% are immunocompromised hosts (5). Cryptococcal infec-

Radiology

#{149}

di-

tion,

Hg)

at Presentation

78

BAL,

2 wk

7.47

29

99

BAL,

CSF

Cryptococcal pulmonary infection in patients with AIDS: radiographic appearance.

The clinical, laboratory, and radiographic findings in seven patients with acquired immunodeficiency syndrome (AIDS) and cryptococcal pulmonary infect...
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